Wiki Modifier 25 Help

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ErinPDX85

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Hi there,

I was hoping for some clarification on when to use modifier 25 in different scenarios. I think my understanding and has been incorrect and I want to remedy that. I scoured the internet and didn’t get the information I sought.

So, I have some examples that I hope you can help me with!

1) Office visit (either preventive or sick) with vaccines. I think a modifier 25 would go on the office visit.
2) Office visit and a lab of some sort (lets say a urinalysis). I do NOT think a 25 is needed.
3) Preventive visit and a vision screen. No NCCI edit, so no need for 25. BUT a sick visit and a vision screen WOULD need a 25 as there is a NCCI edit.
4) Preventive visit and screening questionnaire (96127, 96110) would not need a 25 because no NCCI edit. Same for a sick visit.
5) Sick visit with a nebulizer treatment. I think the office visit would need a 25 because a nebulizer treatment is a minor procedure and is above and beyond that of a regular office visit.
6) Well child visit and a circumcision. These would have separate diagnosis codes so I do not think it would need a 25.
7) Sick visit with a shot of antibiotic. 25 of the office visit because the shot is a minor procedure, just like vaccines.
8) If an office visit bumps against an NCCI edit – and there’s a 1 in the column, do we always do a 25? Or is it a 59? Both?

Sorry for the many examples! I want to be the best coder I can be and am constantly striving to learn more.

Thanks!
 
25 modifier: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59. ** This touches on #8 in your scenarios. 59 is a procedural modifier, not for use on E/Ms.

As for labs with o.v. some payers do require a modifier for this.

ahg,
CPC, CPMA, CGSC
 
As defined by the AMA, modifier 25 indicates a significant, separately identifiable E&M service performed by the same provider on the same day as a procedure or other service. The significant, separately identifiable E&M service goes above and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the primary procedure.
The use of modifier 25 has specific requirements:
1) E/M service must be significant. The problem must ensure physician work that is medically necessary. This can be defined as a problem that requires treatment with a prescription or a problem that would require the patient or family to return for another visit to address it. A minor problem or concern would not warrant the billing of an E/M-25 service.
2) The E/M service must be separate. The problem must be distinct from the other E/M services provided (e.g., preventive medicine) or the procedure being completed on the same day. Separate documentation for the E/M-25 problem is helpful in supporting the use of modifier 25 and especially important to support any necessary denial appeal.
3) The E/M service must be provided on the same day as the other procedure or E/M service. This may be at the same encounter or a separate encounter on the same day.
4) Modifier 25 should always be attached to the E/M code not the procedure code.
5) In case Preventive medicine visit and sick visits are billed, append modifier25 with sick visit code.
6) The separately billed E/M service must meet documentation requirements for the code level selected. It will sometimes be based on time spent counseling and coordinating care for chronic problems.

For your answers:
1) Office visit (either preventive or sick) with vaccines. I think a modifier 25 would go on the office visit.
If an abnormality is encountered during preventive medicine evaluation and management service, and additional workup is planned or performed, then the appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.2) Office visit and a lab of some sort (let’s say a urinalysis). I do NOT think a 25 is needed.
Not required.

3) Preventive visit and a vision screen. No NCCI edit, so no need for 25. BUT a sick visit and a vision screen WOULD need a 25 as there is a NCCI edit.
No NCCI no 25, in case NCCI shows bundling bill with 25 modifier.

4) Preventive visit and screening questionnaire (96127, 96110) would not need a 25 because no NCCI edit. Same for a sick visit.
No 25 required in case no NCCI edit appears.

5) Sick visit with a nebulizer treatment. I think the office visit would need a 25 because a nebulizer treatment is a minor procedure and is above and beyond that of a regular office visit.
25 modifier should be appended in this scenario, and records should indicate an E/M service above and beyond the procedure performed on same day.

6) Well child visit and a circumcision. These would have separate diagnosis codes so I do not think it would need a 25.
If the patient is being seen for a well-child exam and during the exam we identify an "sick" issue, and additional workup is planned for that sick issue then we add the E&M code with a modifier 25.

7) Sick visit with a shot of antibiotic. 25 of the office visit because the shot is a minor procedure, just like vaccines.
The records should depict shot as a separate procedure and not planned for this visit. If so, append 25 modifier.

8) If an office visit bumps against an NCCI edit – and there’s a 1 in the column, do we always do a 25? Or is it a 59? Both?
59 is a procedural modifier, should never be used with E/M codes
 
Last edited:
This is a fantastic article written by Mike Miscoe about modifier 25 that includes all of the regulatory guidance resources you would need to support your decisions. Although not your specific scenarios still relevant.

Quote:
For reimbursement, the provider must sufficiently document the E/M work to report it, and the documentation must demonstrate the E/M work was medically necessary.

Kind Regards,
Steph
 

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